Efficacy of different pretreatments in IVF outcomes in patients with endometriosis: A systematic review and network meta‑analysis

To investigate the efficacy of different pretreatment protocols for women with endometriosis undergoing IVF. We systematically searched the Cochrane Library, PubMed, Medline, and Embase from inception to April 30, 2025, to identify randomized controlled trials (RCTs) evaluating different pretreatment protocols in women with endometriosis undergoing IVF. The primary outcomes were live birth rate and clinical pregnancy rate. Secondary outcomes included miscarriage rate, fertilization rate, implantation rate, gonadotropin dose, and number of retrieved oocytes. This network meta-analysis included 11 randomized controlled trials involving 1,435 women with endometriosis undergoing IVF. No clear improvement in clinical pregnancy rate was observed among the pretreatment protocols compared with the general protocol. For live birth rate, limited evidence from four RCTs suggested a higher rate in the general protocol than in the GnRH-a protocol (RR [95% CI], 2.12 [1.05, 4.31]), but this finding should be interpreted cautiously because of imprecision. Some differences were observed in secondary or intermediate outcomes. The number of retrieved oocytes was significantly higher in the general protocol than in the DNG protocol (MD [95% CI], 0.60 [0.24, 0.97]). The GnRH-a protocol (MD [95% CI], -2.11 [-2.94, -1.28]) and the general protocol (MD [95% CI], -2.45 [-3.50, -1.40]) were associated with lower gonadotropin doses than the DNG protocol. However, these secondary findings did not translate into clear improvements in the prespecified primary clinical outcomes. The results of this network meta-analysis suggest that, compared with the general protocol, pretreatment with GnRH-a or DNG was not associated with clear improvements in the primary clinical IVF outcomes, namely clinical pregnancy rate and live birth rate, in patients with endometriosis. However, the evidence for live birth rate was limited to four RCTs and imprecise; therefore, this finding should be interpreted cautiously. Although some differences were observed in secondary or intermediate outcomes, these findings did not establish the clinical superiority of pretreatment protocols. PROSPERO under identifier: (CRD42024606775).